Introducción de la Educación para el desarrollo

Over the past year, the Department has invested a significant amount of effort and resources to modernize the delivery system design for Medicaid clients in Colorado. The Department is committed to moving from paying for services to paying for improved outcomes and performance. The Department’s goal for an Integrated Delivery System includes continued development of the Accountable Care Collaborative (ACC) as the platform for delivery system reform in Colorado. The ACC drives cost reductions through care coordination, increased primary care capacity, streamlining care delivered to members eligible for both Medicare and Medicaid, and improving delivery of maternal and child health care.

By integrating health care delivery systems, it is possible to improve health outcomes and contain costs through coordinated, member-centric programs that deliver care in a more streamlined, connected manner. Likewise, designing more effective benefits and programs enhances value by ensuring members receive cost-effective, clinically appropriate benefits that emphasize prevention and wellness.

Costs are further controlled by shifting payment systems from outdated “pay and chase” models that drive volume of services to new systems that pay for value and improved health outcomes. These efforts include further development of the ACC and design and implementation plans of the State Innovation Model (SIM) and Innovation Acceleration Plan (IAP). Each of these items is described in this section.

ACCOUNTABLE CARE COLLABORATIVE (ACC) UPDATE

The Accountable Care Collaborative (ACC) is designed to transform the Colorado Medicaid program into an integrated system that increases access to appropriate health care for all its members, improves the long-term health of Colorado Medicaid clients and shifts the Medicaid program to one that focuses on value, not volume. As enrollment continues to grow, the program has a tremendous opportunity to be a driver of changes to the health care delivery system more broadly. The ACC program currently includes over 700,000 Medicaid clients, statewide, and approximately 430 participating Primary Care Medical Providers (PCMPs), which includes over 2,600 rendering practitioners.

The ACC program was designed to be adaptable and to encourage innovation. ACC policy and initiatives foster improvement across the spectrum of health care delivery and target specific areas that have real potential to transform the delivery system and enhance the value of health care in Colorado. Such initiatives include:

ENHANCING PRIMARY CARE

A new incentive will reward PCMPs that meet five out of nine standards for a high-quality, patient-centered medical home. These standards were drawn from those defined by the National Committee for Quality Assurance (NCQA) and adapted to meet the needs of the ACC. As providers stay open on nights and weekends, provide on-site access to behavioral health care providers, collect and regularly update a behavioral health screening (including substance use) for adults and adolescents, and track the status of referrals to specialty care providers, the care for all patients will be improved. Also, this greater access to care and a patient-centered, comprehensive approach will enrich the primary care provider-patient relationship. As these relationships strengthen, individuals will be more likely to seek care from a trusted primary care provider and less likely to rely upon emergency rooms and even specialists.

CONNECTING MEDICAL RESOURCES

Concurrent with strengthening the foundation of the provision of primary care, the ACC is beginning to look at creating medical neighborhoods. A medical neighborhood is a tightly connected, yet flexible, local system with seamless transitions between primary care, specialist care, hospital care, and self-management at home. It is care coordination at its most sophisticated. To support this transition, the Regional Care Collaborative Organizations (RCCOs) developed and provided medical neighborhood/referral protocols that are designed to enhance this work. These protocols are in the initial phases of implementation, and external stakeholders are providing ongoing feedback on their design.

CREATING ACCESS THROUGH TECHNOLOGY

Even with focused development of medical neighborhoods, there is an acute shortage of specialty providers in the State, particularly in rural and frontier areas. The Department is developing a Project ECHO program. Project ECHO is a model that links front-line primary care clinicians with specialist care teams at university medical centers to manage patients who have chronic conditions requiring complex care. With this model, primary care clinicians develop expertise in specific areas, which enables individuals in remote and medically underserved communities to get care they could not easily get before, if at all. The Department believes Project ECHO will foster collaboration between PCMPs and specialists, build expertise among primary care team members, improve the health of clients with chronic conditions, and address prescription drug abuse. This year, there will be a Project ECHO program for pain management, with more Project ECHO Programs to follow beginning in 2015.

CHANGING PATTERNS OF EMERGENCY ROOM UTILIZATION

One key area of focus for the ACC is decreasing inappropriate emergency room (ER) usage. Unnecessary visits to the ER are expensive and are an inefficient way to treat most health care needs. In addition, every unnecessary ER visit potentially channels resources away from more vital and necessary services. Reducing emergency room utilization is a topic that is being addressed nationally, but thus far with mixed results. A number of factors make it difficult to affect the use of the emergency room, including the increase in emergency

rooms and departments, more aggressive advertising by hospitals promoting the use of their emergency room, and a co-pay structure that sometimes makes the emergency room a cheaper option for Medicaid clients.

Over the next fiscal year, the ACC will continue to address ER utilization through these initiatives:

 ER notification to the RCCOs will make it easier for care coordinators and PCMPs to immediately reach out to members and help them avoid further trips to the ER.

 Referral Protocols are being implemented by each RCCO to give structure to medical neighborhoods, facilitating timely and appropriate access to specialty care.

 An enhanced PCMP program that stresses, among other things, afterhours care will help incentivize more providers to have extended hours for appointments.

 Increased emphasis on attributing members to a PCMP, with financial penalties for the RCCOs, will build more medical home relationships for more ACC clients, leading to consistent preventive care and better overall health for ACC members.

ER notification can be a tool used by all payers to support enrollees in using the ER appropriately. As stated above, supporting primary care providers in becoming medical homes, giving them additional training and support through programs like Project ECHO will also have an impact across the delivery system.

PAYING FOR PERFORMANCE OVER VOLUME

Since its inception, the ACC has employed a pay-for-performance program as part of its reimbursement strategy. This program pays RCCOs and PCMPs for consistently meeting quality targets within their region, as measured by Key Performance Indicators (KPI).

KPIs measure quality indicators in the areas of ER usage, well-checks for children ages 3-9, and postpartum care for new mothers. In addition, the ACC makes financial incentives available for increasing adolescent physical and behavioral health screenings, increasing the number of primary care office visits by members who have a diagnosed chronic condition, and ensuring that individuals who have been discharged from the hospital visit a doctor for follow-up care within 30 days of their discharge.

MOVING TOWARD WELLNESS

In the coming year, RCCOs across the State will work more closely with public health to help members and communities embrace wellness. They will collaborate on projects that give communities better access to healthy foods and increase opportunities for physical activity. They will also look for ways to connect with community hospitals who have completed Community Health Needs Assessments.

ACC REPROCUREMENT

From the start, the ACC program is meant to be iterative; it was designed with the understanding that delivery system reform takes time and will require continual evolution. The upcoming request for proposals (RFP) process will re-procure the RCCOs that administer the program on a regional basis.

The RFP will be the basis of the next iteration of the ACC. The RFP will lay out the structural vision for the program, and it will contain specific contract requirements for regional entities to follow in the future.

The approach of the re-procurement has been to identify and build upon successes of the first iteration of the program, while making bold improvements in terms of behavioral health integration, alignment with social services, and new payment reforms.

The re-procurement is focused on three core commitments:

 Transforming systems from a medical model to a health model

 Moving toward person-centered, integrated and coordinated supports and services

 Leveraging efficiencies to provide better quality care at lower costs to more people

In December 2013, the Department began developing the materials necessary for the RFP. Early on, the Department also committed to consistent engagement with the stakeholder community. With the help of the Colorado Health Institute, the Department has held 12 public stakeholder meetings. These meetings, which started in early April, have taken place in all seven of the State's regions.

Additionally, an ACC Request for Information (RFI), released in fall 2014 and open for public response, will help the Department to structure the specifics of many RFP requirements.

The Department is also committed to closer integration between physical health and behavioral health in the next RFP. Integrated care is more effective, efficient, and is capable of addressing co-occurring behavioral health and physical health needs. More coordination is needed both at the system level and at the provider level. The next RFP will support practices in moving towards being integrated clinics. The RFP will also include provisions related to improved data sharing between care coordinators, providers, and other entities so as to improve the quality of client care.

ACC FULL-BENEFIT MEDICARE-MEDICAID (FBMME) PROJECT UPDATE

Colorado is among a small group of states (15) that have partnered with the Centers for Medicare and Medicaid Services (CMS) to improve and integrate care for Full-Benefit Medicare-Medicaid Enrollees (FBMME). In September 2014, Colorado became the 4^th state to begin enrolling FBMME into an improved system of care that will coordinate physical, behavioral, and social health needs.

Colorado’s plan will advance the Department’s commitment to improving the care and health outcomes for FBMME enrollees. It builds on the infrastructure and resources of the Accountable Care Collaborative (ACC), a central part of Colorado’s Medicaid health care delivery system. Colorado’s plan is unique because it allows clients to keep their doctors and existing network of providers. Other states are implementing the demonstration in a managed care setting, which in some cases may require a client to change providers.

The goals of the program are congruent with wider department initiatives, including the Triple Aim:

 Improved health outcomes for full benefit Medicare-Medicaid enrollees.

 Improved enrollee experience through enhanced coordination and quality of care.

 Decreased unnecessary and duplicative services, and the resulting costs.

In order to address these goals, the Department seeks to provide greater integration between the ACC program, other Medicaid programs serving the enrollees, and the Medicare program. It is also working to improve transitions of care into and out of Long-Term Services and Supports (LTSS). Additionally, the Department will make it easier for enrollees to understand their benefits and navigate the systems of care.

HOW DOES THE PROGRAM WORK?

The Department has identified several key strategies that will help meet the goals of the program. These include: the Service Coordination Plan (SCP), cross-provider communication agreements, disability competent care and a beneficiary’s rights and protections alliance.

WHAT IS HAPPENING NOW?

Monthly enrollment will continue until March 2015. The Department is developing an evaluation plan that will utilize rapid cycle feedback to make improvements to the program. The Department is continuing to work with the Advisory Subcommittee and stakeholders to monitor and improve the program.

ACC PAYMENT REFORM PILOT PROGRAM (HB 12-1281) UPDATE

In FY 2014–15, the ACC is launching a payment reform pilot that has been in the planning stages during the past year. Rocky Mountain Health Plans (RMHP), one Regional Care Collaborative Organization (RCCO), is testing a full-risk capitation model with a subset of its members in seven counties in western Colorado. Instead of receiving per-member per-month (PMPM) administrative payments,

RMHP will receive one payment to cover all physical health care delivered to those members. The payment amounts will differ depending on the age, sex, and eligibility type of the member.

RMHP will pay their primary care medical providers (PCMPs) sub-capitation payments, and, at the end of each pilot year, will share savings with their PCMPs and the local community mental health centers (CMHCs). RMHP has included additional payments to PCMPs in advanced practices for the employment of behavioral health providers on comprehensive care teams. The Department will use this pilot to learn more about how to use payment strategies to better integrate care throughout the State.

As of October 1, 2014, approximately 16,200 clients have been enrolled in the pilot program. RMHP and the Department have developed a phased enrollment approach, starting with specific counties, and will eventually enroll approximately 30,000 clients into all seven target counties.

STATE INNOVATION MODEL (SIM)

Under the leadership of the Governor’s Office, the Colorado State Innovation Model (SIM) proposal presents a plan to improve the health of all Coloradans by 2019. To achieve this goal, the State seeks to transform the health care delivery system through the integration of primary care, behavioral health, and public health services. Establishing a strong and ongoing partnership between these three service delivery systems is crucial because health outcomes are strongly impacted by factors beyond the clinical setting, including social, economic, and environmental influences. Key components of the plan include practice transformation support, assistance with transitioning practices to outcomes based payment models, establishment of a statewide data hub, engagement of stakeholders, and a plan to monitor and evaluate all activities.

ACTIVITIES TO DATE

Senior leaders from the Department have partnered with the Governor’s Office, CDPHE, CDHS, the Colorado Health Institute, University of Colorado School of Medicine, and the Center for Improving Value in Health Care to create the vision and plan for the SIM proposal. The proposal was formally submitted by the Governor’s office to the CMS Innovation Center on July 18, 2014 and is currently under consideration. Department leaders remain involved in responding to CMS questions and in planning for a positive response from CMS, including creating workgroups to further activities in key project areas. According to CMS, awards will be announced in early November 2014.

SHARED APPLICATION AND ELIGIBILITY PROCESS

The Single Eligibility System (SES) is a system that will determine eligibility for Medical Assistance (MA), Advanced Premium Tax Credit (APTC), and Cost Sharing Reduction (CSR). CBMS will determine eligibility for Medical Assistance and, in situations where the client is not eligible, the eligibility information will be used to determine APTC and CSR eligibility. The SES is not a system that

is seen by users. The SES is an eligibility system that runs “behind the scenes” when the PEAK User applies for Medical Assistance only.

The following are features of the SES:

ACCOUNT ACCESS

 Applicants and clients will be able to add and designate individuals or agencies to their application to act on their behalf.

SINGLE SIGN-ON

 A single sign-on functionality will allow applicants and clients to login to their account using their PEAK or Connect for Health Colorado login credentials.

 Applicants and clients will be able to use their Connect for Health Colorado login to sign in to PEAK to check the status of their submitted Medical Assistance application.

SINGLE, SHARED APPLICATION

 Applicants and clients will be able to apply for Medical Assistance benefits with one application process and be determined for Medicaid, Child Health Plan Plus (CHP+) or financial assistance to purchase private insurance through the Connect for Health Colorado marketplace. This means applicants will only need to complete one set of questions.

 Applicants will also receive joint letters regarding what program they may qualify.

REAL-TIME ELIGIBILITY DECISIONS

 Real-time eligibility decisions will continue. Over 70% of applications entered into PEAK are currently determined with real-time eligibility.

 Applicants who complete their online application for Medical Assistance completely and accurately may find out immediately if they qualify for Medicaid or CHP+. Those who do not qualify for Medicaid or CHP+ can apply at Connect for Health Colorado and learn right away if they qualify for a tax credit or cost-sharing reduction to help lower their health care costs.